Complications of Intrathecal Baclofen Pump Therapy: An Institutional Experience from Saudi Arabia.

The intrathecal baclofen pump (ITB) is one of the advanced treatment options in the management of spasticity. This retrospective cohort study was conducted to identify the complications of ITB treatment at a tertiary care rehabilitation facility. Various demographic and technical factors were analyzed, which are less often reported in the literature. All patients with ITB who had their refill at the ITB clinic between November 2019 and March 2020 were included. Of 48 patients, 17 patients had 18 (37.5%) ITB-related complications. Catheter-related complications were most common, whereas loss of efficacy (16.7%) and baclofen withdrawal (14.5%) were the most common outcomes of complications. Only catheter occlusion had a significant relationship with the pattern of spastic quadriparesis (p = 0.001). Gender, rehabilitation diagnosis, patients' residence, and facility of ITB placement did not have significant association. Similarly, age, distance from hospital, disease onset, ITB therapy duration, and baclofen dose were not statistically significant in relation to ITB-related complications.

Perceived Clinical Barriers to Employment for Males with Spinal Cord Injury in Saudi Arabia.

Return to work is a challenging aspect of community integration for individuals with disabilities. The reintegration of individuals with spinal cord injury (SCI) is multifactorial; hence, regional challenges need to be investigated in the context of their clinical attributes and perceptions. A total of 121 male participants above 18 years of age with diagnosis of SCI and living at home were included in this cross-sectional survey. The study was conducted at a tertiary care rehabilitation facility in Saudi Arabia. The most common reported clinical barriers to employment were mobility, bladder incontinence, spasticity, musculoskeletal pain, and neuropathic pain. Bladder incontinence and musculoskeletal pain were the most common perceived clinical barriers for individuals with paraplegia and tetraplegia, respectively. A significant difference was observed for bowel incontinence as a reported barrier (p = 0.024) among adults less than thirty years of age in comparison with those older than thirty years. Spasticity as a barrier was reported more among patients who were older than thirty years (54.0%) compared to those younger than thirty years of age (37.9%) (p = 0.077). Twenty-two (23.7%) participants with paraplegia reported transfers as a perceived barrier to employment, which was significant (p = 0.014), and it was also reported as a significant barrier (p = 0.001) in individuals with tetraplegia (56%). This study shows that clinical conditions associated with SCI are considered potential barriers to employment by individuals with SCI. In terms of priority, the perceived barriers between individuals with tetraplegia and paraplegia were mostly different. This shows the need to consider relevant secondary health care conditions in goal setting while planning for employment in individuals with SCI.

Six-minute walk distance, ECOG Performance Status, and Modified Borg Scale scores in a cohort of Pakistani patients with noncancerous end-stage liver disease selected for liver transplant.

OBJECTIVE: To evaluate the functional status of Pakistani patients with non-cancerous end-stage liver disease selected for liver transplant and to compare results acquired through various assessment tools. METHODS: The study was conducted at the Rehabilitation Medicine Department, Shifa International Hospital Islamabad, Pakistan, from August 2017 to November 2019 and comprised end-stage liver disease patients of either gender who had been selected for liver transplant. Assessment tools included the Six-Minute Walk Distance, Eastern Cooperative Oncology Group Performance Status and Modified Borg Dyspnoea Scale across age, gender, ethnicity, primary aetiology, and Model for end-stage liver disease score. Data were analysed using SPSS 20. RESULTS: Of 172 patients, 143(83%) were males; 99(58%) hailed from the Punjab province; and 118(71%) had hepatitis C as the most common aetiology. The overall mean age was 46.1±10.5 years (range: 14-70 years). The mean Six-Minute Walk Distance was 291.9±67.2m. Model for end-stage liver disease score had a significant inverse correlation with Six-Minute Walk Distance (p<0.01) and a significant positive correlation with Modified Borg Dyspnoea Scale (p=0.02) and Eastern Cooperative Oncology Group Performance Status scores (p<0.01). Age and ethnicity had no correlation with the variables (p>0.05). CONCLUSIONS: The Six-Minute Walk Distance was significantly low. The Model for end-stage liver disease score was inversely correlated with Six-Minute Walk Distance score, and positively correlated with Eastern Cooperative Oncology Group Performance Status and Modified Borg Dyspnoea Scale scores.

Progressive Thoracic Kyphoscoliosis leading to Paraplegia in a Child with Neurofibromatosis Type-1.

In this case report we describe a case of a 13-year male with neurofibromatosis type-1, who had been suffering from progressive thoracic kyphoscoliosis that resulted in spinal cord compression and paraplegia. The report is meant to highlight the importance of timely detection and adequate follow-up of spinal deformities, associated with neurofibromatosis. Such deformities, if not effectively addressed, may progress corresponding to skeletal growth and lead to secondary problems, as was seen in our patient, who ultimately developed paraplegia. Key Words: Neurofibromatosis, Kyphoscoliosis, Paraplegia.

Efficacy of intra-articular autologous platelet rich plasma injection in primary knee osteoarthritis: A quasi-experimental study.

OBJECTIVE: To observe the efficacy of platelet rich plasma on pain improvement in knee osteoarthritis patients and to explore the impact of various facotrs on pain reduction with such a treatment. METHODS: The quasi-experimental study was conducted at the Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan, from October 2017 to April 2018 and comprised patients with primary knee osteoarthritis. The sample was sub-grouped into "normal", "overweight" and "obese" on the basis of body mass index. Two age-based sub-groups were also formed at ≤ 60 years and >60 years. Three injections of calcium gluconate activated 2.5ml platelet rich plasma were given in the knees at an interval of two weeks each. The pain score was calculated using the numerical rating scale at the 6th week. Data was analysed using SPSS 20. RESULTS: Of the 50 patients, 26(52%) were females and 24(48%) were males. The overall mean age was 59.6±9.6 years (range: 42-75 years), with 22(44%) aged ≤ 60 years. There were 21(42%) patients who were overweight, 7(14%) had normal weight and 22(44%) were obese. There was significant pain reduction post-treatment compared to the baseline (p<0.001). The reduction in pain was not significantly related to gender, age, knee osteoarthritis grade, or body mass index (p>0.05). CONCLUSIONS: Platelet rich plasma significantly improved pain in knee osteoarthritis patients regradless of all age, gender, grade and body mass index.

Results of carbon dioxide laser-assisted posterior cordotomy in cases of bilateral vocal cord paralysis: An analysis of 34 casest.

Carbon dioxide laser-assisted posterior cordotomy (LAPC) is an effective technique for the treatment of Bilateral Vocal Cord Paralysis (BVCP). For our case series we included 34 patients of BVCP from combined military hospitals of Rawalpindi, Lahore, Malir and Quetta and compiled the results of carbon dioxide LAPC which they underwent under general anesthesia between December 2009 to January 2017. Assessment of voice quality and breathing difficulty was carried out before and six weeks after the operation and graded according to scales. The complications after surgery were also noted. In the study, there were 10 (29.4%) males and 24 (70.6%) females. The mean age of the sample was 39.1 } 13.2 years. Overall, there was an improvement in breathing and mild worsening of voice quality after LAPC. The common complications after LAPC were dysphagia, revision surgery, and post-operative pain in 11.8%, 17.6%, and 17.6% respectively. The study concluded that carbon dioxide LAPC was associated with an improvement in breathing but resulted in a poor voice quality among patients with BVCP, along with a few side effects.

Electrophysiological and etiological evaluation of 119 cases of wrist drop: A single center study.

OBJECTIVE: To explore the pattern of electrodiagnostic findings in cases of wrist drop and compare gender, involved side of the body, and military versus civilian population for the aetiology of wrist drop. METHODS: This cross-sectional study was conducted at Armed Forces Institute of Rehabilitation Medicine Rawalpindi, Pakistan, from August 2013 to December 2014, and comprised wrist drop cases regardless of age or gender. Evaluation was done using XLTEK Neuromax 1004 EMG unit in line with the recommended protocol for electrodiagnostic evaluation of a suspected radial nerve injury(RNI). SPSS 20 was used for data analysis. RESULTS: Of the 119 patients, 97(81.5%) were males, 66(55.5%) were in the 16-30 years' age group, and 96(80.7%) were military personnel. RNI at the mid-arm level was the commonest cause in 88(73.9%) cases. The frequent inciting event was trauma with fracture of the humerus in 39(32.8%) cases. Eighty-four (70.6%) lesions were axonal. Ninety-four (79%) individuals had no associated injury to other nerves. Injuries due to trauma were more frequent in males (p<0.001), on the right side (p=0.046), and in the military population (p=0.05). CONCLUSIONS: RNI at the mid arm level was the commonest cause of wrist drop in our sample and fracture of the humerus was the main inciting event..

Spontaneous spinal epidural hemorrhage following disseminated intravascular coagulation resulting in paraplegia: a case report.

CONTEXT: Spontaneous spinal epidural hemorrhage (SSEH) mostly presents as low back pain with or without a radiculopathy, and rarely with paraplegia or tetraplegia depending on the site and severity of spinal cord compression. We present here a case who had anemia and developed paraplegia following disseminated intravascular coagulation (DIC) due to a transfusion reaction. FINDINGS: A 65-year-old lady presented with sudden onset chest pain radiating to nape of the neck followed by loss of sensations and power in legs few hours after a blood transfusion. Her past history was negative for diabetes mellitus, hypertension, coronary artery disease, or a bleeding disorder. Her blood pressure was 90/57 mmHg and she had a normal pulse, respiratory rate, and temperature. On neurological examination, she had no motor power and unevokable muscle stretch reflexes in the lower limbs. The sensations were intact till T3 dermatome. The laboratory evaluation was suggestive of DIC. The magnetic resonance imaging showed a non-enhancing abnormal signal intensity area in the posterior epidural space, extending from CV4 to LV4 causing cervico-dorsal cord compression associated with cord edema. Following diagnosis, urgent decompressive surgery was carried out due to deteriorating neurological status. The patient was transfused with five bags of red cell concentrate, two bags of platelets, and four bags of fresh frozen plasma during the operation. The patient regained consciousness following operation, however, the neurological status did not improve. She, unfortunately, died on the third post-op day due to cardiac arrest. CONCLUSION: SSEH is a rare cause of paraplegia. Early radiological diagnosis is crucial for timely neurosurgical management and saving patient from permanent neurological deficit or a fatal outcome.

Bilateral spontaneous anterior shoulder dislocation: A missed orthopedic injury mistaken as proximal neuropathy.

A number of orthopedic injuries can occur during epileptic seizures. Anterior shoulder dislocation is one such orthopedic injury that is quite rare. The shoulder dislocation may injure the brachial plexus. Besides seizures, the nerves can also be damaged by anticonvulsive therapy. Muscle wasting following a seizure can misguide a clinician to investigate only neural or muscular pathologies. We report here an individual with epilepsy who was referred to us for electrodiagnostic evaluation of proximal muscle wasting related to a suspected proximal neuropathy. He was found to have a normal electrodiagnostic evaluation and later on discovered to have had bilateral shoulder dislocation on X-rays. This report advocates a thorough clinical appraisal, radiographs, and electrodiagnostic evaluation in a case with muscle wasting following a seizure.

Framingham Risk Scores for coronary heart disease in a cohort of Saudi Arabian men and women with spinal cord injury.

People with spinal cord injury (SCI) are at increased risk of developing coronary heart disease (CHD). This study aimed at predicting CHD risk in a cohort of Saudi patients with SCI in comparison with patients without SCI and to correlate different demographic and clinical factors with Framingham Risk Score (FRS) in SCI patients. The study was conducted at the rehabilitation and the main hospitals of King Fahad Medical City, Riyadh, Saudi Arabia; on sixty patients with SCI and sixty controls of age ≥20 years. FRS was calculated on a web-based calculator. For the SCI group, sub-groups were made for statistical analysis based on gender, cigarette smoking, neurological level and completeness of injury. The mean FRS for the SCI group (2 ± 7.9) was significantly higher (P < 0.001) than the control group (-2.24 ± 3.4). The 10-year risk of developing CHD was low in 90 % of the SCI group and 100 % of the controls. The age, systolic blood pressure (SBP) and serum total cholesterol had a positive correlation to FRS in SCI patients and females had a significantly higher mean FRS than males (P = 0.03). There was no significant relation of resultant FRS with time since SCI, smoking history and neurological level or completeness of injury. Our sample of Saudi patients with SCI had a higher FRS as compared to controls, however, majority had a low risk of developing CHD in next 10 years. The age, SBP and total cholesterol surfaced as positive predictors of CHD in SCI patients. Time since SCI, smoking, and neurological level or completeness of injury did not influence the resultant FRS and thus the development of CHD.

Longitudinal cleavage of the penis in chronic spinal cord injury: two case reports.

CONTEXT: Penile cleavage is a rare complication of spinal cord injury (SCI) in patients with a chronic indwelling catheter. We report two cases of chronic SCI who developed penile urethral cleavage after prolonged use of an indwelling catheter for bladder management. FINDINGS: A 25-year-old wheelchair mobile male with T7 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A paraplegia developed a 4 × 1.5 cm ventral urethral cleavage after using an indwelling catheter for four months with inadequate care. He had an associated urinary tract infection and undiagnosed diabetes mellitus. A suprapubic catheter was inserted and surgical repair recommended after resolution of UTI and adequate control of his diabetes mellitus. After initial treatment he was lost to follow-up. The second patient was a 15-year-old male with AIS grade B tetraplegia who presented with a 2.5 cm cleavage on the ventral aspect of penis for the preceding three months. He had been using an indwelling catheter for bladder management for the previous 18 months. He had modified Ashworth scale grade III spasticity in lower limbs resistant to conservative management. There was no history of trauma, infection or diabetes mellitus. The patient was advised penile urethral repair surgery but was lost to follow-up. CONCLUSION: Penile cleavage is a rare complication of neurogenic bladder in SCI patients. Patients and care givers should be trained in proper bladder management techniques during the hospital stay, counseled regarding the need for regular follow up, and be taught identification and prevention of common complications.

Conversion Disorder; an Unusual Etiology of Unilateral Foot Drop.

PURPOSE: Foot drop is generally a consequence of common peroneal or sciatic nerve injury or L5 radiculopathy but rarely, it can be a manifestation of conversion disorder. CASE REPORT: A 24-year-old male presented with a foot drop on left side that developed overnight. He had difficulty walking with a trunk tilt towards right side and numbness in left leg up to mid-thigh. The initial diagnosis by the general practitioner was common peroneal nerve injury, which was not supported by the subsequent detailed examination in the physiatry department. Routine laboratory investigations, computed tomographic scan of brain and electrophysiological evaluation were normal. In a multidisciplinary team evaluation involving a psychiatrist, he was diagnosed to be suffering from conversion disorder and was advised gait retraining, cognitive and behavioral therapy and tablet venlafaxine. By sixth day of treatment, the patient was able to walk independently with a normal gait pattern and reported complete recovery of his symptoms. CONCLUSION: In the absence of an identifiable organic cause of foot drop in a patient, conversion disorder may be considered necessitating early intervention by a psychiatrist.

The diagnostic dilemma of progressive muscular atrophy.

Progressive muscle atrophy is a rare subtype of motor neuron disease that affects only the lower motor neurons and presents as asymmetrical rapidly progressive muscle weakness, atrophy and normal sensations. The diagnostic electrophysiological findings are denervation potentials in three out of four body segments (bulbar, cervical, thoracic and lumbosacral). The disease is fatal and the management is supportive. We present the report of a 45-year-old female patient who presented with unilateral foot drop and rapidly progressed to profound weakness in muscles of all limbs, neck and back along with dysarthria and dysphagia. She had been operated twice for suspected cervical and lumbosacral intervertebral disc herniations and ultimately guided in right direction after muscle biopsy, nerve conduction studies and electromyography.

Spinal cord injury secondary to front rolls as part of military physical training: a case report.

OBJECTIVE: To report an unusual case of cervical spinal cord injury. STUDY DESIGN: Case report of a 23 year old soldier who sustained spinal cord injury in front rolls during a military training program. SETTINGS: Spinal Cord Injuries Unit, Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan. CASE REPORT: A 23 year old soldier, who voluntarily joined a military training program, suffered spinal cord injury in doing front rolls resulting in tetraplegia and incontinence for bowel and bladder corresponding to the injury level of C5 ASIA Impairment Scale C with Functional Independence Measure Score of 40/126. His Magnetic Resonance Imaging showed posterior displacement of CV3 resulting in cord compression and swelling at CV3 and CV4 levels. He was managed conservatively by comprehensive rehabilitation and improved to spinal cord injury C5 ASIA Impairment Scale D with Functional Independence Measure Score of 76/126. CONCLUSION: This case report describes spinal cord injury secondary to front-rolls. As front-rolls are part and parcel of military training, awareness and coaching to ensure safety must be exercised from the beginning of any training program.